Surgical Management in Ulcerative Colitis


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Surgical Management in Ulcerative Colitis

  2. 2. UC & CRC
  3. 3. INCIDENCE <ul><li>CRC in UC appears at younger age than in sporadic CRC (40-50 yrs old vs 60). </li></ul><ul><li>5-10% after 20 years. </li></ul><ul><li>12-20% after 30 years. </li></ul>
  4. 4. RISK FACTORS <ul><li>Duration of the disease </li></ul><ul><li>Extent of the disease </li></ul><ul><li>UC complicated by primary sclerosing cholangitis </li></ul><ul><li>Presence of post-inflammatory pseudopolyp </li></ul>
  5. 5. CRC in UC… <ul><li>Appears as: </li></ul><ul><ul><li>Polypoid </li></ul></ul><ul><ul><li>Nodular </li></ul></ul><ul><ul><li>Ulcerated </li></ul></ul><ul><ul><li>Plaque like </li></ul></ul><ul><li>Mostly adenocarcinoma. </li></ul><ul><li>Mostly located in the rectum and sigmoid </li></ul><ul><li>It arises from areas of dysplasia. </li></ul>
  6. 6. <ul><li>Dysplastic areas may appear flat or slightly raised areas. </li></ul><ul><li>Dysplastic areas may occur within or near nodules, masses, polyps or plaque like lesion. </li></ul><ul><li>N.B.: Diagnosis of dysplasia in Pre Op colonoscopy has a: </li></ul><ul><ul><li>81% sensitivity </li></ul></ul><ul><ul><li>79% specifty </li></ul></ul>
  7. 7. Surgical management in UC
  8. 8. Indications for surgery in UC: <ul><li>SURGICAL EMERGENCIES </li></ul><ul><ul><li>Massive life threatening hemorrhage </li></ul></ul><ul><ul><li>Toxic megacolon with impending perforation </li></ul></ul><ul><ul><li>Fulminant colitis unresponsive to IV corticosteroids  </li></ul></ul><ul><ul><li>  Colonic perforation </li></ul></ul><ul><ul><li>  Total obstruction from stricture </li></ul></ul>
  9. 9. <ul><li>Elective: </li></ul><ul><ul><li>Intractability despite max therapy. </li></ul></ul><ul><ul><li>Mucosal dysplasia </li></ul></ul><ul><ul><li>Dysplasia-associated lesion or mass (DALM) </li></ul></ul><ul><ul><li>Intolerable side effects of medications </li></ul></ul><ul><ul><li>Patient with significant risk to develop CRC </li></ul></ul><ul><ul><li>Stricture formation without obstruction </li></ul></ul>
  10. 10. <ul><ul><li>Extraintestinal manifestations </li></ul></ul><ul><ul><li>Growth retardation, primarily in children and adolescents </li></ul></ul>
  11. 11. <ul><li>Surgical Options </li></ul>
  12. 12. Emergency operation: <ul><ul><li>Subtotal colectomy with end ileostomy </li></ul></ul><ul><ul><li>Proctocolectomy with end ileostomy </li></ul></ul><ul><ul><li>Blow-hole colostomy with end ileostomy </li></ul></ul>
  13. 13. <ul><ul><li>Subtotal colectomy with end ileostomy </li></ul></ul><ul><ul><li>Advantages : Allows option for IPAA; low risk </li></ul></ul><ul><ul><li>Disadvantages : </li></ul></ul><ul><ul><ul><li>Requires second operation </li></ul></ul></ul><ul><ul><ul><li>may develop rectal recurrence of disease </li></ul></ul></ul><ul><ul><li>Contraindication : Massive hemorrhage from colon and rectum </li></ul></ul>
  14. 14. <ul><li>Proctocolectomy with end ileostomy: </li></ul><ul><ul><li>Advantages: Definitive treatment </li></ul></ul><ul><ul><li>Disadvantages : </li></ul></ul><ul><ul><ul><li>No option for IPAA </li></ul></ul></ul><ul><ul><ul><li>moderate risk for perineal nerve damage </li></ul></ul></ul><ul><ul><li>Contraindication : Severely toxic or unstable patient </li></ul></ul>
  15. 15. <ul><ul><li>Blow-hole colostomy with end ileostomy </li></ul></ul><ul><ul><li>Advantages: Short, simple decompression procedure </li></ul></ul><ul><ul><li>Disadvantages : Diseased colon and rectum retained </li></ul></ul>
  16. 16. ELECTIVE PROCEDURES <ul><ul><li>Total proctocolectomy with Brooke ileostomy </li></ul></ul><ul><ul><li>Subtotal colectomy with ileorectal anastomosis </li></ul></ul><ul><ul><li>Total proctocolectomy with Kock pouch </li></ul></ul><ul><ul><li>Total colectomy, mucosal proctectomy and hand-sewn IPAA with temporary diverting loop ileostomy (two-stage operation) </li></ul></ul><ul><ul><li>Total proctocolectomy without mucosectomy and stapled IPAA with temporary diverting loop ileostomy (two-stage operation) </li></ul></ul>
  17. 17. <ul><ul><li>Laparoscopic total proctocolectomy with or without mucosectomy and IPAA </li></ul></ul>
  18. 18. Total proctocolectomy with Brooke ileostomy <ul><ul><ul><li>Indications : Patients wanting to avoid risks of IPAA; elderly; poor sphincter function; rectal cancer </li></ul></ul></ul><ul><ul><ul><li>Contraindications : Patient aversion to permanent ileostomy; obesity; life-threatening emergencies </li></ul></ul></ul><ul><ul><ul><li>Advantages : Eliminates all disease-bearing mucosa; single operation </li></ul></ul></ul><ul><ul><ul><li>Disadvantages: Potential for nerve injury in the perineal and pelvic dissection; permanent ileostomy; delayed perineal wound healing; mechanical problems with stoma; high risk of SBO </li></ul></ul></ul>
  19. 20. Subtotal colectomy with ileorectal anastomosis <ul><ul><li>Indications: No rectal involvement; avoid permanent stoma and IPAA; young women of childbearing age to preserve fertility </li></ul></ul><ul><ul><li>Contraindications : Poor sphincter tone or dysfunction; active rectal or perianal disease; colonic or rectal dysplasia; or frank cancer </li></ul></ul><ul><ul><li>Advantages: One-stage operation; complete continence with good function; low risk of pelvic nerve injury; eliminates stoma. </li></ul></ul>
  20. 21. <ul><ul><li>Disadvantages: </li></ul></ul><ul><ul><ul><li>30% Recurrence rate requiring conversion to ileostomy </li></ul></ul></ul><ul><ul><ul><li>Risk of rectal cancer requiring lifelong surveillance </li></ul></ul></ul>
  21. 23. Total proctocolectomy with Kock pouch <ul><ul><li>Indications : Alternative to conventional ileostomy for patients desiring to preserve continence; poor sphincter tone; low rectal cancer; failed IPAA; conversion from ileostomy </li></ul></ul><ul><ul><li>Contraindications : Possibility of Crohn's disease; previous resection of small bowel; patients over 60 years old; obesity; coexisting medical illness </li></ul></ul>
  22. 24. <ul><ul><li>Advantages: Avoids ileostomy; patients remain continent; good quality of live; improved body image over ileostomy </li></ul></ul><ul><ul><li>Disadvantages: High reoperation rate (35%) due to nipple valve dysfunction or failure; high fistula rate; pouchitis </li></ul></ul>
  23. 26. Total Proctocolectomy with Ileal Pouch–Anal Anastomosis <ul><ul><li>Indications : Procedure of choice for ulcerative colitis; colonic dysplasia or cancer; indeterminate colitis </li></ul></ul><ul><ul><li>Contraindications : Poor resting tone or anal sphincter dysfunction; low rectal cancers </li></ul></ul><ul><ul><li>Advantages: Completely restorative; mucosectomy eliminates all disease-bearing mucosa; no disease recurrence; no cancer risk; good function, continence, and quality of life. </li></ul></ul>
  24. 27. <ul><ul><li>Disadvantages: </li></ul></ul><ul><ul><ul><li>Two-stage procedure </li></ul></ul></ul><ul><ul><ul><li>potential for nerve injury in the perineal and pelvic dissection </li></ul></ul></ul><ul><ul><ul><li>reduced fertility in females </li></ul></ul></ul><ul><ul><ul><li>mucosectomy and hand-sewn IPAA are technically demanding and difficult to learn </li></ul></ul></ul><ul><ul><ul><li>septic complications </li></ul></ul></ul><ul><ul><ul><li>pouchitis </li></ul></ul></ul>
  25. 29. <ul><li>Operative Techniques: </li></ul><ul><ul><li>Stage I : abdominal colectomy, mucosal proctectomy, endorectal IPAA, and diverting loop ileostomy </li></ul></ul><ul><ul><li>Stage II : clousre of ileostomy </li></ul></ul>
  26. 30. <ul><li>preoperative work-up </li></ul><ul><ul><li>anal manometry </li></ul></ul><ul><ul><li>Sigmoidoscopy </li></ul></ul><ul><ul><li>bowel preparation </li></ul></ul>
  27. 33. The Lone Star retractor
  28. 35. <ul><li>construction of the ileal pouch </li></ul>
  29. 36. <ul><li>ileal J-pouch </li></ul><ul><ul><li>faster </li></ul></ul><ul><ul><li>less tedious to create </li></ul></ul><ul><ul><li>use considerably less ileum </li></ul></ul><ul><ul><li>have similar or better functional results than other pouch configurations. </li></ul></ul>
  30. 40. <ul><li>Post-IPAA: </li></ul><ul><ul><li>4 weeks after - barium radiographic study </li></ul></ul><ul><ul><li>8 weeks after - anal manometry + clousre of ileostomy </li></ul></ul><ul><ul><li>1 – 3 – 6 – 12 month F/U then every year </li></ul></ul><ul><ul><li>flexible fiberoptic pouchoscopy with surveillance biopsies of the ileal pouch approximately every 5 years. </li></ul></ul>
  31. 41. Complications <ul><li>Pouch Failure </li></ul><ul><li>Pouchitis </li></ul><ul><li>Crohn's Disease </li></ul><ul><li>dysplasia and carcinoma of the ileal pouch </li></ul>
  32. 42. Pouch Failure <ul><li>significant long-term complication of IPAA </li></ul><ul><ul><li>Prior anal pathology </li></ul></ul><ul><ul><li>Abnormal anal manometry </li></ul></ul><ul><ul><li>Pouch-perineal or pouch-vaginal fistulae </li></ul></ul><ul><ul><li>Pelvic sepsis </li></ul></ul><ul><ul><li>Anastomotic stricture, and dehiscence </li></ul></ul><ul><li>Brooke ileostomy or Kock pouch </li></ul>
  33. 43. Pouchitis <ul><li>nonspecific, idiopathic inflammation of the ileal pouch </li></ul><ul><li>most common and significant late, long-term complication </li></ul><ul><li>> 50% of ulcerative colitis patients </li></ul><ul><li>Rare in IPAA for FAP </li></ul>
  34. 44. <ul><li>Presentation : </li></ul><ul><ul><li>stool frequency </li></ul></ul><ul><ul><li>watery diarrhea </li></ul></ul><ul><ul><li>fecal urgency </li></ul></ul><ul><ul><li>Incontinence </li></ul></ul><ul><ul><li>abdominal cramping </li></ul></ul><ul><ul><li>fever, and malaise </li></ul></ul><ul><li>flexible ileal pouchoscopy </li></ul>
  35. 46. <ul><li>the greatest risk for experiencing an episode is during the initial 6-month period following closure of the temporary diverting loop ileostomy. </li></ul><ul><li>Risk continues to rise steadily for the next 18–36 months before leveling off at around 4 years </li></ul>
  36. 47. <ul><li>Management : </li></ul><ul><ul><li>Broad-spectrum antibiotics </li></ul></ul><ul><ul><ul><li>Acute: </li></ul></ul></ul><ul><ul><ul><ul><li>Ciprofloxacin 250 mg BID </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Metronidazole 250 mg QID </li></ul></ul></ul></ul><ul><ul><ul><li>Chronic: ( treatment for 3 months ) </li></ul></ul></ul><ul><ul><ul><ul><li>Ciprofloxacin 250 mg OD </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Metronidazole 250 mg OD </li></ul></ul></ul></ul><ul><ul><ul><ul><li>topical anti-inflammatory agents, corticosteroids </li></ul></ul></ul></ul><ul><ul><ul><li>Refractory : </li></ul></ul></ul><ul><ul><ul><ul><li>undiagnosed Crohn's disease ? </li></ul></ul></ul></ul>
  37. 48. Crohn's Disease <ul><li>severe morbidity and a significant risk of pouch excision </li></ul><ul><li>Predictors : </li></ul><ul><ul><li>complex perianal or pouch fistulae </li></ul></ul><ul><ul><li>ileitis proximal to the pouch </li></ul></ul><ul><ul><li>Afferent limb ulcers </li></ul></ul><ul><li>biological therapies </li></ul>
  38. 49. <ul><li>THANK YOU </li></ul>